Buried healing cap: advice?

I placed an immediate implant in tooth #10 site in a 40 yr old male last Thursday. I placed some DFDB mix in the gap between the facial wall and the implant (greater than 1.5mm).  I placed a 2 mm healing cap and a PTFE membrane, instead of the usual cover screw. Should I take it out and place a cover screw and new membrane? Constructive advice appreciated. Thanks.



26 thoughts on: Buried healing cap: advice?

  1. harold Castañeda says:

    Hello dear Dr.
    In my opinion, you could leave it and take it out later. Probably, you would have to place a higher and longer healing cap in the second stage surgery.
    Regards,
    Harold

  2. WJ Starck DDS says:

    I guess I don’t understand the reasoning behind your question?

    Please tell us why you think you should do that?

    • ez says:

      Usually I do this procedure with a flat cover screw so the PTFE is in intimate contact over the bone/implant. In this case the PTFE is tenting the area over the healing abutment and I am not sure what will fill in below the healing abutment and whether that “space” may be a nidus for infection.

  3. Dr AZ says:

    Excellent case. I like your implant positioning and preference for immediate implant. I would have loved to load the implant if possible. In this case, I would let the implant heal without changing the healing abutment. You might risk compromising implant stability while changing the abutment. Let it heal and deal with it in stage 2.

  4. Gregori M Kurtzman DDS says:

    leave it there will be no problems. when ready to restore you will need to uncover it so make a semi lunar incision to the palatal and slide the tissue facially to expose the cover screw. remove it place a temp abutment and make a screw retained temporary to train the soft tissue.

  5. Matthew Osepchook says:

    I agree with Kurtzman and Dr. AZ. Additionally when uncovering you might expect to have to recontour the bone slightly. If you placed the membrane over the healing cap it will tent the membrane and possibly allow a bit of bulk of bone growth around the implant, though it will not grow onto your healing abutment. In some cases bone will grow right over a cover screw. No problem! If you have a bit of excess bone and it is not recontoured (very conservatively) then the gingival contour may change down the road….which is not a problem unless it exposes a metal collar.

  6. Zach says:

    So, lets think of the rationale and the answer will be clear. You immediately placed the implant into what appears to be a good position. You grafted the buccal gap to ensure a thickness of buccal plate for long term success. You placed a membrane (non resorbable) after a 2mm healing collar. So, you did not mention if: 1. you obtained primary closure of the socket 2. How was the remaining band of attached gingiva after the procedure. 3. What are you temporizing with. 4. What was your insertion torque value. While these 4 factors do not address the question you are asking, they are important in this particular procedure. As far as the healing collar is concerned. During an immediate placement procedure, you are typically either placing a cover screw, graft, membrane, etc. or placing a graft and healing collar that emerges out of the socket and gingiva if you have about 25 N/CM and if you have 30 or more, you can temporize. The use of the extension tube on the Implant Direct Legacy implant while doing no harm will not give you any benefit in this case. Wait for Stage 2, uncover and temporize to develop soft tissue. Do not try to remove as your reverse torque value during screw loosening might exceed your insertion torque value which could disturb the healing cascade.

    • ez says:

      1. almost primary closure, not worried PTFE. 2. Plenty of attached gingiva 3. don’t know yet re. #3. 4. I used a hand ratchet wrench ( I prefer hand wrenches) which does not have a torque value setting, but my guess around 30ncm.

  7. Ajay Kashi, DDS, PhD says:

    I don’t see any issues with you leaving it as is until second stage. You can place the healing abutment at that time to contour the soft tissue before impressions for a crown. Good luck !
    Ajay Kashi, DDS, PhD

  8. Dr Jerome BHUNJUN says:

    Hi there, Looks great, have done this several times, In spite of the fact that the top of the screw is covered, a non-négligeable benefit is that 5 months down the line, all around the neck of the future abutment(in my case Ankylos) I will have keratinised (or partially) soft tissue and that’s a great benefit.

  9. Steve Hochfelder says:

    If concerned with infection or nidus for infection place pt on antibiotics for first 10 days after immediate placement. Looks very nice position of implant. My question was what was wrong with lateral to need replacement short of good portion of coronal tooth missing. Could not a P&C and emax crown done to restore tooth? Just a question. Seems at least radiographically like restorable tooth. Lastly i would restore adjacent canine with crown when lateral restored with crown for ideal esthetics. Thank you for sharing case

    • ez says:

      you could but the amount of bone to remove would be excessive with a large crown to root ratio. Furthermore this patient has a high smile line and the crown lengthening would create an uneven gingival architecture on the contralateral side.

  10. Dr. Gerald Rudick says:

    Further thought…. after looking at the pre-op xray, the tooth you extracted and replaced with an implant ……..in my opinion could have been easily restored, and an implant would not have been necessary…….

    • Steve Hochfelder says:

      That is exactly what i was alluding to in my post/comment. Along those lines i have learned that often radiograph’s only tell part of the story and at times can be misleading. In this particular case my initial reaction was it was very much a restorable case. Lastly this forum is to learn and grow as practicioner’s and not call out or criticize our fellow dentists so i always try to bring up concerns in a proper manner.

  11. Nidal says:

    Hi, as you mentioned PTFE membrane used which is recommended to be removed after 10 days to 2 weeks when you get soft tissue margins healed, by pull it out, so the tent effect of this membrane will be removed and the soft tissue will heal around the healing collar or mostly it will cover it totally. good luck.

    • Steve Hochfelder says:

      I agree. Because we now have the implant option perhaps many overtreat in my opinion with extraction and implant. If bridge were only other option i think we would (and use to) see a lot less extractions. Lastly i find quite challenging to get ideal esthetic result with single implant in anterior ( 6-11 area).

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